- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,640.07 / $2,640.07 / $2,640.07
| Professional | | $2,640.07 | $2,640.07 | $2,640.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,981.00 / $6,745.00 / $8,094.00
| Professional | | $5,981.00 | $6,745.00 | $8,094.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,333.24 / $4,333.24 / $4,333.24
| Professional | | $4,333.24 | $4,333.24 | $4,333.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,803.62 / $5,638.65 / $8,741.93
| Professional | | $2,803.62 | $5,638.65 | $8,741.93 |